Pterygium growth in the right eye of a 35-year-old male patient who works as a professional gardener. It has been slowly growing over the course of the last decade.

Essentially all ophthalmologists agree that phacoemulsification is usually the best form of cataract surgery for patients in the U.S. But what about the technique of pterygium surgery? There are so many ways to remove a pterygium, with no single technique being widely accepted as the best.

While small pterygia are considered more of a cosmetic issue than a functional problem, as the pterygia grow onto the cornea they begin to affect vision. Initially this may be due to induced corneal irregularities, but it may progress to chronic inflammation, ocular surface disruption and frank blockage of the visual axis.

There are many described techniques and adjunctive therapies: simple excisions, conjunctival autografts, amniotic membrane grafts, sutured vs. glued grafts, mitomycin C application, even radiation.

Because the prevalence of pterygium in other countries is more than in the U.S., international ophthalmologists may have more experience and better techniques to treat these patients. Because this blog has as many international readers as U.S. readers, I'd like to pose the question:

For the patient shown in this picture, what technique of pterygium surgery would you recommend?

See Dr. Devgan share more expert insight live at OSN New York 2010, to be held November 19-21, 2010 at the Sheraton New York Hotel & Towers. Learn more at OSNNY.com.

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There are now multiple studies that show cataract surgery helps to lower IOP in eyes with glaucoma. And for many patients, the best initial glaucoma surgery may actually be our tried-and-true cataract surgery. But what about performing cataract surgery in eyes that have already had glaucoma surgery?

Cataract surgery in an eye with prior glaucoma surgery.

Intraoperatively, the primary difficulty is the balance of fluidics.

In phacoemulsification, we want to keep the inflow of fluid greater than the outflow of fluid in order to maintain the anterior chamber and keep the posterior capsule away from our instruments. Fluidic surge is simply the condition when, even for a fraction of a second, the outflow of fluid is more than the inflow. This can lead to instability of the anterior chamber and rupture of the posterior capsule.

In eyes with prior glaucoma surgery, there is an additional outflow tract for our irrigating fluid. This means that at any given time, the outflow of fluid is greater than we're used to. To rebalance the inflow:outflow ratio, we can increase the inflow, decrease the outflow, or both.

To increase the inflow, the infusion bottle is raised so that the effect of gravity is greater and the inflow pressure is increased. To decrease the outflow, we can lower the flow rate from a peristaltic pump, keep our incisions tighter so they don't leak, and limit the flow through the glaucoma surgical site. In eyes with seton shunts, this may entail placing a temporary suture in or around the tube to limit outflow. In eyes with trabeculectomies, a bolus of viscoelastic can be placed to act as a barrier to outflow. At the end of surgery, the suture is removed or the viscoelastic is aspirated and these patients tend to do very well.

Get more expert perspective from Dr. Devgan live at Hawaiian Eye 2010, to be held January 17-22, 2010 at the Grand Hyatt Kauai. Learn more at OSNHawaiianEye.com.

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Iris capture by the IOL optic.

A patient presents a week after cataract surgery at the UCLA resident ophthalmology clinic with a complaint of pain in the eye of sudden onset. At the slit lamp, the optic is prolapsed through the pupil and overriding the inferior half of the iris.

The patient's original cataract surgery was complicated by posterior capsule rupture and vitreous loss, and a three-piece acrylic lens was placed into the ciliary sulcus. Now the patient has iris capture by the IOL optic, a myopic shift from the anterior displacement of the lens, and induced astigmatism from the tilt of the optic.

When the capsule ruptures, placement of the IOL becomes more challenging. In cases of a small posterior capsule defect, the IOL may still be placed in the capsular bag. Alternatively, the IOL haptics may be placed into the ciliary sulcus if it is a three-piece design, with multiple options available for the optic: The optic can be left in the sulcus (like in this patient), it can be captured behind the anterior capsulorrhexis, or it can be captured behind a posterior capsulorrhexis.

If the optic is left in the sulcus, care should be taken to use a posterior vaulted IOL in which the optic is angulated approximately 10° behind the haptics. In this case, a planar IOL was used, and we have iris capture of the optic.

What do you do to help this patient?

Get more expert perspective from Dr. Devgan live at Hawaiian Eye 2010, to be held January 17-22, 2010 at the Grand Hyatt Kauai. Learn more at OSNHawaiianEye.com.

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